Healthcare Provider Details

I. General information

NPI: 1639548332
Provider Name (Legal Business Name): CYNTHIA CALVARIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 02/15/2022
Certification Date: 02/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 VICTORIA ST STE 1H
COSTA MESA CA
92627-1906
US

IV. Provider business mailing address

11902 ROSECRANS AVE
NORWALK CA
90650-4197
US

V. Phone/Fax

Practice location:
  • Phone: 949-629-2860
  • Fax:
Mailing address:
  • Phone: 562-929-7188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number2114332I
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: